Provider Demographics
NPI:1154493518
Name:MCCLENDON, MARK A (DMD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:A
Last Name:MCCLENDON
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1230 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:CENTRE
Mailing Address - State:AL
Mailing Address - Zip Code:35960-1122
Mailing Address - Country:US
Mailing Address - Phone:256-927-8275
Mailing Address - Fax:256-927-8275
Practice Address - Street 1:1230 W MAIN ST
Practice Address - Street 2:
Practice Address - City:CENTRE
Practice Address - State:AL
Practice Address - Zip Code:35960-1122
Practice Address - Country:US
Practice Address - Phone:256-927-8275
Practice Address - Fax:256-927-8275
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL48601223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice